Skip to main content

The US Centers for Medicare and Medicaid Services (CMS) will move away from its current practice of randomly selecting claims for audit in favor of a more targeted approach that it hopes will streamline the process and result in fewer appeals.

The program, dubbed Targeted Probe and Educate, directs Medicare administrative contractors (MACs) to select claims for items or services "that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate," focusing only on "providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers." The program was piloted in 1 MAC jurisdiction in 2016, and expanded to 3 more in July of this year. All MAC jurisdictions will be following the procedure "later in 2017," according to a CMS fact sheet.

Once a claim and provider have been targeted, MACs will begin a multiphase process by probing 20-40 claims per provider. If the provider is found to be noncompliant, the provider must participate in education on meeting requirements. After the education phase, the MAC must wait 45 days or more before reviewing another batch of 20-40 claims. At that point, the MAC can either determine that the provider is in compliance or submit the provider to another round of education and later review. Should a third review round not make a difference in compliance, the provider will be referred to CMS for possible further action.

The new process moves away from the "Probe and Educate" program, a less-targeted process that resulted in more reviews—and more appeals from providers. According to an article in Modern Healthcare, CMS has 667,000 pending appeals and expects that number to rise to 687,000 by the end of 2017, and more than 1 million by 2021.


You Might Also Like...

Article

Code Pairing Edits: Four Things To Know

Jan 25, 2021

APTA successfully advocated for CMS to lift misguided coding edits, and we're working to bring commercial payers around.

Review

CMS Fast-Tracks 'Breakthrough Devices,' Clarifies 'Reasonable and Necessary'

Jan 19, 2021

CMS has finalized a new pathway that could result in quicker coverage of cutting-edge FDA-approved medical devices.

Review

CMS Takes Aim at Prior Authorization in Medicaid, CHIP, and Federal Exchanges

Jan 19, 2021

The final rule pushes payers toward more transparency and consistent deadlines for decisions.